CITY OF MODESTO Community and Economic Development Department/Planning Division 1010 Tenth Street, Suite 3300, P.O. Box 642 Modesto, CA 95353 (209) 577-5267 (209) 491-5798 FAX This questionnaire will assist the Community & Economic Development Department, Planning Division in evaluating the proposed project and it s potential environmental impacts. Complete and accurate information will facilitate the environmental assessment and review, and will minimize future requests for additional information. GENERAL INFORMATION If the proposal is a component of an overall larger project, describe the phases below and indicate them on the site plan: If this project (as a whole, or) is part of another project for which a negative declaration or environmental impact report has been prepared by or for the City or County, please indicate name and document below: Will the project require certification, authorization, or issuance of a permit by any public agency other than the City of Modesto? Yes No If yes, indicate what agencies: Associated Projects: SCHOOL INFORMATION School District(s) serving site: ENVIRONMENTAL SETTING (site characteristics) 1. Are there any known environmental conditions affecting the site, such as proximity to a floodplain, known biological, historical or cultural resources on or in immediate proximity to the site? 2. If yes, describe.
Page 2 of 5 4. Describe the surrounding properties. Indicate the type of land use (residential, commercial, etc.), intensity of land use (singlefamily residential, apartments, shopping center, office building, etc.), and the scale of development (height, frontage, setback, rear yard etc.). 5. Will the project increase noise, dust, light and glare, or use hazardous materials? If yes, discuss: CERTIFICATION I hereby certify that the statements furnished above and in the attached exhibits present the data and information required for this initial evaluation to the best of my ability, and that the facts, statements, and information presented are true and correct to the best of my knowledge and belief. Date Signature (Applicant/agent) Phone No.: Print Name and Title (Applicant/agent)
Page 3 of 5 Hazardous Waste Site Certification: INSTRUCTIONS: 1. This certificate must be completed with an application for a development project or tentative map application. 2. The applicant shall consult the most current list of hazardous waste sites list as found at http://www.calepa.ca.gov/sitecleanup/corteselist/default.htm and shall specify whether or not the development project is located on a site included on the list. Attach complete hazardous waste list with Notice of Intent, Environmental Information application. FORM: The undersigned owner(s), applicant(s) or their legal representative(s) of the lands for which this development project application is made, hereby certify under penalty of perjury under the laws of the State of California that: In accordance with Section 65962.5(e) of the Government Code of the State of California: He/She has consulted the most current and appropriate list of Identified Hazardous Waste Sites County of Stanislaus and further certifies that the site of the proposed development project (check applicable box and fill in date of list): a. Is not located on a site included on the list entitled Identified Hazardous Waste Sites County of Stanislaus, dated. b. Is located on a site included on the list entitled Identified Hazardous Waste Sites County of Stanislaus, dated. List Assessor s Parcel Numbers of the project property. Signatures of Applicants/Owners of Record Attach additional sheets if necessary Date
Page 4 of 5 GOVERNMENT CODE SECTION 65962.5 List of Hazardous Waste and Substance Sites; Submission to California Environmental Protection Agency Hazardous Materials Data Management Program (A) The Department of Toxic Substances shall compile and update as appropriate, but at least annually, and shall submit to the California Environmental Protection Agency (Cal/EPA), Hazardous Materials Data Management Program, a list of all of the following: (1) All hazardous waste facilities subject to corrective action pursuant to Section 25187.5 of the Health and Safety Code. (2) All land designated as hazardous waste property or border zone property pursuant to Article 11 (commencing with Section 25220) of Chapter 6.5 of Division 20 of the Health and Safety Code. (3) All information received by the Department of Toxic Substances Control Pursuant to Section 25242 of the Health and Safety Code on hazardous waste disposals on public land. (4) All sites listed pursuant to Section of the Health and Safety Code. (5) All sites included in the Abandoned Site Assessment Program. (6) A list of all public drinking water which contain detectable levels or organic contaminants and which are subject to water analysis pursuant to Section 4026.2 or 4026.3 of the Health and Safety Code. (B) The State Water Resources Control Board shall compile and update as appropriate, but at least annually, and shall submit to the California Environmental Protection Agency, a list of all of the following: (1) All underground storage tanks for which an unauthorized release report is filed pursuant to Section 25295 of the Health and Safety Code. (2) All solid waste disposal facilities from which there is a migration hazardous waste and for which California Regional Water Quality Control Board has notified the State Department of Toxic Substances Control pursuant to subdivision (e) of Section 13273 of the Water Code. (3) All cease and desist orders issued after January 1, 1986, pursuant to Section 13301 of the Water Code, which concern the discharge of wastes, which are hazardous materials. (C) (D) (E) The local enforcement agency, as designated pursuant to Section 18051 of Title 14 of the California Administrative Code, shall compile as appropriate, but at least annually, and shall submit to the California Waste Management Board, a list of all solid waste disposal facilities from which there is a known migration of hazardous waste. The California Waste Management Board shall compile the local lists into a statewide list, which shall be submitted to the California Environmental Protection Agency and shall be available to any person who requests the information. The California Environmental Protection Agency shall consolidate the information submitted pursuant to this section and distribute it in a timely fashion to each city and county in which sites on the lists are located. Before a local agency accepts as complete an application for any development project which will be used by any person, the applicant shall consult the lists sent to the appropriate city or county and shall submit a signed statement to the local agency indicating whether the project is located in a site which is included on any of the lists compiled pursuant to this section. If the site is included on a list, the list shall be specified on the statement. (F) This section shall be become operative on July 1, 1987.
Page 5 of 5 NOTICE TO ALL APPLICANTS Pursuant to California Fish & Game Code 711.4, the City of Modesto is required to collect the following filing fees for the Stanislaus County Clerk, on behalf of the California Department of Fish & Game, for the following projects: 1. Any project for which a Finding of Conformance with the General Plan Master EIR: $57.00 County documentary handling fee for Department of Fish & Game. 2. Any project for which a Negative Declaration or Mitigated Negative Declaration is prepared pursuant to the California Environmental Quality Act: $2156.25 [Fish & Game Code 711.4(d)(2)] plus a $57.00 County documentation handling fee. 3. Any project for which an Environmental Impact Report is prepared pursuant to the California Environmental Quality Act: $2,995.25 [Fish & Game Code 711.4(d)(3)] plus a $57.00 County documentation handling fee. THESE FEES WILL BE COLLECTED AT THE TIME THAT THE APPLICATION IS READY FOR HEARING, NOT AT APPLICATION INTAKE. THE PLANNING DIVISION WILL NOTIFY THE APPLICANT WHEN THESE FEES ARE DUE. (checks to be made out to Stanislaus County Clerk-Recorder)